No: …
People’s Committee SOCIALIST
REPUBLISH OF VIETNAM Form BTP/HT-2006-KS.1.a
Village / Ward: … Independence – Freedom – Happiness No:
…
District:
… Book
No: …
City
/ Province: …
BIRTH CERTIFICATE
(ORIGINAL)
Full name: THACH THIA Sex:
Male
Date of birth: 20 / 09 / … by words: The twentieth of September ….
Place of birth: Hamlet 2, Phong Phu, Cau Ke, Tra Vinh
Ethnic group: Khmer Nationality:
Vietnamese (Khmer Krom)
Native place: Hamlet 2, Phong Phu, Cau Ke, Tra Vinh
Full name of the father: …
Ethnic group: Khmer Nationality:
….
Full name of the mother: ….
Ethnic group: Khmer Nationality:
….
Full name of the declarer: THACH THIA
Relationship with the person declared: SELF-DECLARED
Signature of the declarer Judicial status Registered on August 28th
2007
(signed) (signed)
For the people’s Committee of … Village
THACH
THIA NGUYEN VAN NHAN Vice
Chairman
(Signed and sealed)
TRAN QUOC TUAN
I, Thach Thia, certify that the document is exactly translated
from the original document written in English.
Chiang Mai, Feb. 17th
2013
Translator
THACH THIA